Question 1

Findings associated with severe quadriceps contusions include:

Explanation

A severe quadriceps contusion is defined as having less then one-third the normal knee range of motion and can be accompanied by a sympathetic knee effusion and, sometimes, a mild extensor lag. Two-thirds the normal knee range of motion is classified as a moderate quadriceps contusion.

Question 2

The proposed site of pathology for athletes with groin pain and diagnosed with athletic pubalgia is:

Explanation

Athletic pubalgia syndrome is the result of trunk hyperextension and thigh hyperabduction. This can result in injury to the rectus abdominus insertion and origin of the adductor longus muscle. By definition, a hernia is not present. The pectineus and sartorius muscles are not implicated in athletic pubalgia.

Question 3

The initial management of athletic pubalgia consists of:

Explanation

The initial management of athletic pubalgia consists of a period of rest followed by core trunk stabilization, stretching, and gradual return to functional activities. Despite reports of low success rates after nonoperative treatment, this management must be instituted prior to surgical considerations. Reattachment of the inferolateral edge of the rectus using a modified Bassini repair has resulted in return to sports activities for the majority of patients, but the procedure should follow a nonoperative trial. Adductor release can be part of the operative approach after failure of nonoperative management. Hip joint pathology is not consistently associated with athletic pubalgia.

Question 4

The most common physical finding in patients with athletic pubalgia is:

Explanation

In a series of 157 high-performance athletes diagnosed with athletic pubalgia, 88% of patients had pain with resisted hip adduction. Peripubic tenderness was found in one-fourth of patients. By definition, a hernia is not present. Less than one-third of patients had tenderness at the origin of the adductor longus, and less than one-half of patients had pain with resisted situps.

Question 5

Magnetic resonance imaging (MRI) of the pelvis in patients with athletic pubalgia reveals:

Explanation

Although only 12% of patients with athletic pubalgia will demonstrate MRI abnormalities, more than 90% of patients will have nonspecific findings localized to the symptomatic side. Labral pathology is not a common finding in patients diagnosed with athletic pubalgia.

Question 6

Adductor longus tenotomy in athletes with chronic adductor pain resistant to nonoperative treatment results in:

Explanation

In a series of 16 athletes undergoing adductor tenotomy for chronic adductor symptoms, 12 patients returned to competitive sports at a mean 14 weeks after surgery. A decrease in objective strength was noted that did not affect functional results.

Question 7

In order of frequency, the most common compartments involved in chronic exertional compartment syndrome are:

Explanation

The most common compartment involved in chronic exertional compartment syndrome in athletes is the anterior compartment followed by the deep posterior compartment and lateral compartments. The superficial posterior compartment is only rarely involved.

Question 8

The resting pressure criteria for diagnosing chronic exertional compartment syndrome in athletes is equal to or greater than:

Explanation

The criteria for diagnosing chronic exertional compartment syndrome from compartment pressure measurements include one or more of the following: More than or equal to 15 mm Hg resting pressure A 1-minute postexercise pressure of more than or equal to 30 mm Hg A 5-minute postexercise pressure of more than or equal to 20 mm Hg

Question 9

The postexercise pressure measurement criteria for diagnosing chronic exertional compartment syndrome are:

Explanation

The criteria for diagnosing chronic exertional compartment syndrome from compartment pressure measurements includes one or more of the following: More than or equal to 15 mm Hg resting pressure A1-minute postexercise pressure of more than or equal to 30 mm Hg A5-minute postexercise pressure of more than or equal to 20 mm Hg

Question 10

Success rates after fasciotomy for chronic exertional compartment syndrome are highest for which compartment:

Explanation

In a series of patients undergoing fasciotomy for anterior or deep posterior chronic exertional compartment syndrome, satisfactory results were obtained in 96% and 65% of patients, respectively. The superficial posterior compartment is rarely involved.

Question 11

Which of the following is not a common finding in patients presenting with chronic exertional compartment syndrome:

Explanation

Patients with chronic exertional compartment syndrome will give a history of cramping or aching pain and occasional numbness with exercise. The symptoms typically resolve within minutes of rest. Most patients will have a normal initial examination unless they have exercised minutes prior to evaluation. Increased postexercise compartment pressures are diagnostic.

Question 12

The initial recommended treatment for a grade 3 acute lateral ankle sprain is:

Explanation

A review of 12 prospective studies comparing surgery, casting, and functional bracing with early range of motion revealed 75% to 100% excellent or good results regardless of treatment. The final recommendation was functional bracing.

Question 13

Earlier return to work and sport is reported after which treatment for acute lateral ligament sprain:

Explanation

Studies comparing surgery, immobilization, and early weight bearing and range of motion have shown that early weight bearing and range of motion result in earlier return to sport and work when compared to acute operative management or cast immobilization.

Question 14

Which of the following leads to lower success rates after lateral ankle ligament repair (modified Brostrom):

Explanation

Patients with generalized ligamentous laxity have fewer satisfactory results after a modified Brostrom repair. Overall, 91% of patients had good to excellent results after this procedure, but none of the five patients with generalized ligamentous laxity had an excellent result.

Question 15

With regard to the level of athletics, which group of patients can be expected to have less satisfactory results after lateral ankle repair using a modified Brostrom technique:

Explanation

In a series of 28 ankles undergoing a modified Brostrom repair for lateral ankle instability, there were no significant differences in outcome whether the patients were professional dancers, athletes, or non-athletes.

Question 16

The foot and ankle position that is most likely to result in disruption of the anterior talofibular ligament is:

Explanation

Strain in the anterior talofibular ligament increases with plantarflexion, inversion, and internal rotation. It is the primary restraint to anterior displacement, internal rotation, and inversion of the talus at all angles of flexion and is the most commonly injured ligament as a result of inversion ankle sprains.

Question 17

Which of the following arteries provides the primary blood supply to the supraspinatus tendon:

Explanation

The suprascapular artery provides the primary vascular supply to the supraspinatus tendon. The vascularity predominates on the bursal side, while the articular side is hypovascular.

Question 18

Thermal shrinkage of the shoulder capsule imparts which of the following properties on the capsule:

Explanation

Thermal shrinkage reliably decreases capsular stiffness (increasing compliance). The resultant tissue is biomechanically weaker than normal tissue.

Question 19

Ligaments and joint capsule are primarily composed of collagen. What is the predominant type of collagen in these structures:

Explanation

As thermal modification of soft tissue becomes a common procedure, orthopedic surgeons must have an understanding of collagen. Type I collagen predominates in ligaments, joint capsule, bone, tendon, meniscus, annulus of intervertebral disks, and skin. Type II collagen predominates in articular cartilage and nucleus pulposus of intervertebral disks. Type V collagen is found in small amounts in articular cartilage, as is types VI and IX.

Question 20

Magnetic resonance imaging will demonstrate labral abnormalities in the throwing shoulder in approximately what percentage of asymptomatic professional baseball pitchers:

Explanation

Miniaci and colleagues discovered that 79% of asymptomatic professional baseball pitchers had labral abnormalities on magnetic resonance imaging. They further discovered that the incidence of labral lesions was similar between throwing and nonthrowing shoulders in this population.

Question 21

What is the primary pathophysiologic mechanism thought to underlie the development of athletic pubalgia (sports hernia) in elite athletes?

Explanation

Athletic pubalgia involves a complex of injuries, primarily attenuation or tearing of the rectus abdominis insertion and the transversalis fascia at the pubis. This creates an imbalance with the strong adductor pull, exacerbating groin pain.

Question 22

Which of the following factors most significantly increases the risk of developing myositis ossificans following a severe quadriceps contusion?

Explanation

Premature return to play leading to reinjury, early aggressive massage, and passive stretching are known risk factors for myositis ossificans. Immobilization in 120 degrees of flexion actually optimizes outcomes and limits hematoma size.

Question 23

Surgical repair is most strongly indicated for a proximal hamstring avulsion in an athlete when there is:

Explanation

Operative treatment is generally recommended for complete 3-tendon (conjoined tendon and semimembranosus) avulsions from the ischial tuberosity with >2 cm of retraction. This prevents profound weakness and sciatic nerve tethering.

Question 24

A professional soccer player sustains an acute, complete proximal adductor longus avulsion. What is the most appropriate initial management for an isolated injury?

Explanation

Acute, isolated complete ruptures of the adductor longus in athletes are typically managed nonoperatively with excellent results. Surgery is rarely indicated unless there is a large bony avulsion or chronic pain recalcitrant to therapy.

Question 25

In an athlete with femoroacetabular impingement (FAI), a Cam lesion typically damages the hip joint by causing:

Explanation

A Cam lesion creates shear forces during hip flexion and internal rotation. This leads to outside-in delamination of the adjacent anterosuperior acetabular cartilage and secondary labral tearing.

Question 26

An elite runner presents with chronic groin pain exacerbated by kicking and sprinting. Radiographs show symphyseal sclerosis and widening. What is the most reliable diagnostic injection to confirm osteitis pubis as the primary pain generator?

Explanation

A targeted fluoroscopic or ultrasound-guided injection of local anesthetic into the pubic symphysis is the most reliable way to confirm osteitis pubis. It differentiates this condition from intra-articular hip pathology or athletic pubalgia.

Question 27

A dancer complains of a painful, audible snap on the lateral aspect of the hip when moving from flexion to extension. Which anatomical structure is primarily responsible for this external snapping hip?

Explanation

External snapping hip (coxa saltans) is caused by the posterior border of the iliotibial band or the anterior border of the gluteus maximus snapping over the greater trochanter. Iliopsoas snapping causes internal snapping hip.

Question 28

A 35-year-old female runner presents with deep posterior gluteal pain radiating down the posterior thigh. MRI reveals edema in the quadratus femoris muscle. What is the most likely diagnosis?

Explanation

Ischiofemoral impingement results from a narrowed space between the lesser trochanter and the ischium. This leads to compression and characteristic MRI edema or atrophy of the quadratus femoris muscle.

Question 29

A football player sustains a direct helmet blow to the iliac crest, presenting with severe pain, swelling, and inability to bear weight. Radiographs are negative. Which of the following muscles is most commonly injured in this "hip pointer" contusion?

Explanation

A "hip pointer" is a contusion of the iliac crest and/or the associated muscular insertions. It most commonly affects the external and internal obliques and the transverse abdominis muscles.

Question 30

Which of the following best describes the anatomical origin of the reflected head of the rectus femoris, which may be avulsed in a kicking athlete?

Explanation

The rectus femoris has two origins. The direct head originates from the AIIS, while the reflected head originates from the superior acetabular rim and the anterior hip joint capsule.

Question 31

Acute compartment syndrome of the thigh is rare but can occur following severe quadriceps contusion or femur fracture. Which compartment is most frequently involved?

Explanation

The anterior compartment of the thigh is the most commonly affected in acute thigh compartment syndrome. This usually follows femur fractures, severe blunt trauma, or complications from anticoagulation.

Question 32

A rugby player presents 1 week after a severe tangential blow to the lateral thigh with a large, fluctuant mass over the greater trochanter. What is the primary pathophysiology of this Morel-Lavallée lesion?

Explanation

A Morel-Lavallée lesion is a closed degloving injury where a shearing force separates the skin and subcutaneous tissue from the underlying investing fascia. The resulting potential space fills with blood, lymph, and necrotic fat.

Question 33

Which physical examination finding is most specific for diagnosing piriformis syndrome in an athlete with buttock pain and sciatica?

Explanation

Piriformis syndrome involves sciatic nerve compression by the piriformis muscle. Pain is typically provoked by stretching the muscle (passive internal rotation) or by active contraction (resisted external rotation).

Question 34

An athlete undergoes arthroscopic release for recalcitrant internal snapping hip syndrome. During the release at the level of the joint capsule, which structure is at greatest risk of iatrogenic injury?

Explanation

The femoral nerve lies immediately medial to the iliopsoas muscle belly. When performing an endoscopic release of the iliopsoas tendon at the joint level, care must be taken to stay on the tendinous portion to avoid nerve injury.

Question 35

A 20-year-old soccer player developed myositis ossificans in the vastus intermedius following a contusion 6 weeks ago. Radiographs show immature, fluffy ossification. What is the most appropriate management?

Explanation

Early surgical excision of myositis ossificans is contraindicated due to a high risk of recurrence. The mass should be allowed to mature over 6 to 12 months with conservative management before considering excision.

Question 36

In an athlete undergoing surgical repair for athletic pubalgia (core muscle injury), which anatomic structure is most frequently reinforced or repaired?

Explanation

Surgery for athletic pubalgia typically involves repairing and reinforcing the insertion of the rectus abdominis and the transversalis fascia. This restores core stability and balances the pull of the adductor origin.

Question 37

A 14-year-old hurdler presents with acute buttock pain after a race. Radiographs show a displaced 2 cm bone fragment inferior to the acetabulum. Which muscle group is responsible for this avulsion?

Explanation

The ischial tuberosity is the origin of the hamstring muscle group. In skeletally immature athletes, sudden forceful contraction can cause an avulsion fracture of the ischial apophysis.

Question 38

Which specific clinical test helps differentiate athletic pubalgia from femoroacetabular impingement (FAI) in a hockey player with vague groin pain?

Explanation

The resisted sit-up test directly engages the rectus abdominis and is classically positive in athletic pubalgia. The FADIR test is sensitive for intra-articular hip pathology such as FAI and labral tears.

Question 39

An MRI of a professional sprinter demonstrates an isolated, complete rupture of the direct head of the rectus femoris with 3 cm of retraction. What is the recommended treatment?

Explanation

Isolated ruptures of the proximal rectus femoris, even with retraction, typically heal well with nonoperative management. Surgery is rarely indicated except in cases of chronic, severe weakness or massive heterotopic ossification.

Question 40

A 22-year-old female marathon runner presents with insidious onset groin pain. MRI reveals a tension-sided stress fracture of the femoral neck involving 50% of the neck width. What is the standard of care?

Explanation

Tension-sided (superior) femoral neck stress fractures have a high risk of displacement and subsequent avascular necrosis. Prophylactic internal fixation is the absolute standard of care to prevent catastrophic displacement.

Question 41

A football player sustains a severe quadriceps contusion. To minimize the risk of prolonged stiffness and myositis ossificans, how should the affected limb be immobilized in the first 24 hours?

Explanation

Early immobilization of the knee in 120 degrees of flexion limits hematoma formation and maintains muscle length. This significantly reduces the time to return to play and the risk of myositis ossificans.

Question 42

A 22-year-old dancer presents with a painful snapping sensation deep in her anterior groin when extending her hip from a flexed, abducted, and externally rotated position. Which anatomical structure is most likely involved?

Explanation

Internal snapping hip (coxa saltans interna) is caused by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head. It typically occurs when the hip is moved from a flexed, abducted, externally rotated position into extension.

Question 43

Which of the following is the most widely accepted indication for acute surgical repair of a proximal hamstring avulsion injury?

Explanation

Acute surgical repair of proximal hamstring avulsions is strongly recommended for tears involving all three tendons (complete avulsion) with greater than 2 cm of retraction. This prevents significant loss of power, deformity, and chronic pain.

Question 44

A 30-year-old cyclist falls and slides on the pavement, sustaining a large, fluctuant swelling over the lateral aspect of the greater trochanter without a fracture. What is the underlying pathophysiology of this lesion?

Explanation

A Morel-Lavallée lesion is a closed degloving injury where post-traumatic shearing forces separate the subcutaneous tissue from the underlying deep fascia. This creates a potential space that fills with blood, lymph, and necrotic fat.

Question 45

A 25-year-old hockey player diagnosed with athletic pubalgia undergoes surgical repair of the posterior inguinal wall but continues to experience significant groin pain postoperatively. Which concomitant condition was most likely missed during the initial evaluation?

Explanation

There is a highly recognized association between athletic pubalgia (core muscle injury) and femoroacetabular impingement (FAI). Failure to diagnose and concomitantly treat FAI is a leading cause of persistent groin pain after athletic pubalgia surgery.

Question 46

When performing an open repair of a proximal hamstring avulsion, the surgeon identifies the conjoined tendon. Which muscles form this specific anatomical structure at the ischial tuberosity?

Explanation

The proximal hamstring origin at the ischial tuberosity consists of the conjoined tendon (long head of the biceps femoris and the semitendinosus) and the distinct, more lateral and anterior origin of the semimembranosus.

Question 47

A 19-year-old soccer player experiences a sudden pop in his anterior pelvis while kicking. MRI confirms an isolated avulsion of the direct head of the rectus femoris. What is the specific anatomical origin of this tendon?

Explanation

The rectus femoris has two distinct origins: the direct (straight) head originates from the anterior inferior iliac spine (AIIS), and the indirect (reflected) head originates from the superior acetabular rim and joint capsule.

Question 48

A 24-year-old rugby player developed myositis ossificans after a severe thigh contusion 6 weeks ago. He is being considered for surgical excision due to persistent pain and restricted knee flexion. Which imaging finding best indicates that the lesion is safe for excision?

Explanation

Surgical excision of myositis ossificans should only be performed after the lesion has fully matured, typically 6-12 months post-injury. CT scanning best demonstrates this maturation, characterized by peripheral ossification and a sharply circumscribed border, reducing the risk of recurrence.

Question 49

A 35-year-old female presents with chronic deep gluteal pain that worsens with long strides. MRI demonstrates narrowing of the ischiofemoral space. Which muscle is typically compressed and shows edema or atrophy in this condition?

Explanation

Ischiofemoral impingement syndrome is characterized by a narrowed space between the lesser trochanter and the ischial tuberosity. This anatomical narrowing compresses the quadratus femoris muscle, leading to edema, fatty replacement, and deep gluteal pain.

Question 50

In the surgical management of athletic pubalgia (core muscle injury), repair most commonly addresses the attenuation or tearing of which specific anatomical structure?

Explanation

Athletic pubalgia involves a weakening or tearing of the posterior inguinal wall, specifically the transversalis fascia, and often includes pathology at the insertion of the rectus abdominis and the origin of the adductor longus on the pubis.

Question 51

A professional water skier sustains a forced hyperabduction injury to his hip, resulting in acute medial groin pain. Examination reveals an ecchymotic mass in the medial thigh and weakness in hip adduction. What is the most common site of injury in this scenario?

Explanation

Acute injuries to the adductor muscle group most frequently involve the adductor longus. Ruptures typically occur at its proximal origin near the pubic symphysis, often treated nonoperatively, though surgery may be considered for elite athletes with significant retraction.

Question 52

A 28-year-old male distance runner complains of insidious onset anterior pelvic pain that radiates to the lower abdomen and bilateral groins. Radiographs reveal subchondral sclerosis, cystic changes, and widening of the pubic symphysis. What is the most appropriate initial treatment?

Explanation

Osteitis pubis is an overuse inflammatory condition of the pubic symphysis. The cornerstone of initial management is conservative, including rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy aimed at core and pelvic stabilization.

Question 53

A 21-year-old female runner complains of a painful, audible click on the lateral aspect of her hip when climbing stairs. On physical examination, the snapping is reproduced when the hip is actively flexed and extended while in a lateral decubitus position. Which test is most useful for confirming the tight structures involved in this pathology?

Explanation

This patient has external snapping hip syndrome, caused by a tight iliotibial (IT) band snapping over the greater trochanter. The Ober test assesses IT band tightness, which is the primary underlying cause of this condition.

Question 54

A 55-year-old female presents with chronic lateral hip pain, refractory to extensive physical therapy and multiple corticosteroid injections. MRI demonstrates a high-grade, retracted tear of the gluteus medius tendon without fatty atrophy. What is the most appropriate next step in management?

Explanation

Greater trochanteric pain syndrome (GTPS) often involves gluteus medius or minimus tendinopathy or tearing. In patients with high-grade, retracted tears who have failed prolonged conservative management and lack irreversible fatty atrophy, surgical repair is indicated and yields good functional outcomes.

Question 55

A 40-year-old former sprinter presents with chronic, deep buttock pain radiating down the posterior thigh, exacerbated by sitting. He has a history of a remote hamstring strain. Examination reveals a positive seated slump test and localized tenderness at the ischial tuberosity. What is the likely diagnosis?

Explanation

Hamstring syndrome involves entrapment or irritation of the sciatic nerve by dense fibrotic scar tissue around the ischial tuberosity, typically following a prior proximal hamstring injury. It presents with deep buttock pain radiating down the posterior thigh, worsened by sitting.

Question 56

A 15-year-old gymnast presents with acute anterior pelvic pain after performing a split leap. Radiographs reveal an avulsion fracture of the anterior superior iliac spine (ASIS). Which muscle is responsible for this avulsion?

Explanation

Avulsion fractures of the anterior superior iliac spine (ASIS) are typically caused by the sudden, forceful contraction of the sartorius muscle, or occasionally the tensor fasciae latae. The rectus femoris avulses the AIIS, while the iliopsoas avulses the lesser trochanter.

Question 57

Which of the following interventions has been shown to decrease the risk of developing myositis ossificans following a severe quadriceps contusion in an athlete?

Explanation

Early active pain-free knee flexion and avoiding aggressive passive stretching or massage decrease the risk of myositis ossificans. Immobilization in extension is strictly contraindicated as it leads to stiffness and worsened outcomes.

Question 58

A 22-year-old sprinter feels a pop in his buttock during a race. MRI shows a complete proximal avulsion of the conjoint tendon of the biceps femoris and semitendinosus with 3 cm of retraction. What is the most appropriate management?

Explanation

Surgical repair is indicated for proximal hamstring avulsions involving 2 or more tendons with greater than 2 cm of retraction, especially in high-level athletes to restore function.

Question 59

Internal snapping hip syndrome (coxa saltans interna) is most commonly caused by which of the following structures snapping over the iliopectineal eminence or femoral head?

Explanation

Internal snapping hip is typically caused by the iliopsoas tendon snapping over the iliopectineal eminence or the anterior femoral head. It is often reproduced with active extension of the flexed, abducted, and externally rotated hip.

Question 60

During physical examination, a patient with chronic groin pain demonstrates pain with a resisted sit-up and resisted hip adduction. MRI shows edema at the rectus abdominis insertion. Which anatomic structure is most commonly attenuated in this condition?

Explanation

Athletic pubalgia (core muscle injury) often involves attenuation or tearing of the posterior inguinal wall (transversalis fascia) and the common aponeurosis of the rectus abdominis and adductor longus.

Question 61

A 15-year-old soccer player reports acute groin pain after powerfully striking a ball. Radiographs reveal an avulsion fracture of the anterior inferior iliac spine (AIIS). Which muscle is responsible for this injury?

Explanation

The direct head of the rectus femoris originates from the AIIS and is responsible for avulsion fractures at this site during forceful hip flexion and knee extension, such as kicking.

Question 62

A professional hockey player presents with chronic groin pain. Radiographs show symphyseal sclerosis and widening. A single-leg stance (flamingo) view shows 3 mm of superior translation of the pubis. What is the most likely diagnosis?

Explanation

Symphyseal sclerosis, joint widening, and instability on single-leg stance (flamingo) views are hallmark radiographic findings of osteitis pubis. This is commonly seen in hockey players and distance runners.

Question 63

Which radiographic measurement on a Dunn lateral radiograph is most indicative of Cam-type femoroacetabular impingement (FAI)?

Explanation

An alpha angle greater than 50-55 degrees on a lateral hip radiograph indicates a decreased anterior head-neck offset, which is characteristic of Cam-type FAI.

Question 64

A 35-year-old distance runner presents with deep posterior gluteal pain. MRI reveals narrowing of the space between the lesser trochanter and the ischium with edema in the quadratus femoris muscle. What is the diagnosis?

Explanation

Ischiofemoral impingement is characterized by the narrowing of the ischiofemoral space. It typically presents with deep buttock pain and edema or tears in the quadratus femoris muscle on MRI.

Question 65

Which of the following clinical tests is most specific for diagnosing piriformis syndrome in an athlete?

Explanation

The FAIR test (Flexion, Adduction, Internal Rotation) stretches the piriformis muscle, compressing the sciatic nerve and reproducing the radicular symptoms characteristic of piriformis syndrome.

Question 66

A 16-year-old gymnast experiences a sudden 'pop' over her right anterior pelvis while performing a split jump. She has localized tenderness over the anterior superior iliac spine (ASIS). Which structure is injured?

Explanation

The sartorius muscle originates from the ASIS and can avulse this apophysis during forceful hip flexion. The rectus femoris avulses the AIIS.

Question 67

In the non-operative management of a severe quadriceps contusion, what is the target time-frame to achieve 120 degrees of knee flexion to minimize the risk of prolonged disability?

Explanation

Achieving 120 degrees of pain-free knee flexion within 7-10 days is a key milestone in the non-operative rehabilitation of severe quadriceps contusions to ensure early return to play.

Question 68

Which of the following is the most dreaded and functionally limiting complication of surgical repair of a chronic proximal hamstring avulsion?

Explanation

The sciatic nerve is in close proximity to the proximal hamstring origin (approximately 1.2 cm away). In chronic repairs, scar tissue often tethers the nerve, making iatrogenic sciatic nerve injury a high risk.

Question 69

A 45-year-old female presents with lateral hip pain and a positive Trendelenburg sign. MRI shows a high-grade tear of the gluteus medius tendon at its insertion. Which facet of the greater trochanter is the primary insertion site for the gluteus medius?

Explanation

The gluteus medius primarily inserts onto the lateral and superoposterior facets of the greater trochanter. The gluteus minimus inserts on the anterior facet.

Question 70

Which structure forms the medial border of the femoral triangle, a relevant landmark when evaluating groin pain in an athlete?

Explanation

The femoral triangle is bounded superiorly by the inguinal ligament, laterally by the medial border of the sartorius, and medially by the medial border of the adductor longus.

Question 71

A football player sustained a direct blow to the iliac crest, termed a 'hip pointer'. He now complains of altered sensation over the gluteal region and lateral hip. Which nerve is most susceptible to injury in this direct contusion?

Explanation

A hip pointer is a contusion to the iliac crest. The iliohypogastric nerve and superior cluneal nerves cross the iliac crest and are susceptible to crush injury, leading to sensory deficits.

Question 72

What is the primary pathophysiology behind Pincer-type femoroacetabular impingement (FAI)?

Explanation

Pincer FAI is caused by focal or global acetabular overcoverage (e.g., retroversion, coxa profunda), leading to impingement of the femoral neck against the prominent acetabular rim.

Question 73

A 28-year-old professional hockey player is diagnosed with an acute grade II strain of the adductor longus. Which of the following is the most appropriate initial management?

Explanation

Most adductor longus strains, including grade II partial tears, are managed non-operatively with a brief period of rest, ice, and early functional rehabilitation, yielding high return-to-play rates.

Question 74

A patient with suspected athletic pubalgia undergoes a diagnostic local anesthetic injection. Which anatomical structure is typically targeted to confirm the diagnosis of a rectus abdominis/adductor longus aponeurotic plate injury?

Explanation

A diagnostic injection into the pubic cleft or the rectus/adductor aponeurosis can help localize the pain generator in suspected athletic pubalgia, confirming the diagnosis if symptoms temporarily resolve.

Question 75

During surgical intervention for recalcitrant external snapping hip syndrome, what structure is typically lengthened or released?

Explanation

External snapping hip is caused by the iliotibial band (or anterior border of the gluteus maximus) snapping over the greater trochanter. Surgical treatment involves IT band lengthening, such as a Z-plasty or crucial release.

Question 76

Which of the following physical exam findings is considered the most sensitive test for anterior femoroacetabular impingement and labral pathology?

Explanation

The FADIR (Flexion, Adduction, Internal Rotation) test is highly sensitive for anterior intra-articular hip pathology, including anterior FAI and labral tears, as it provokes mechanical impingement.

Question 77

A 22-year-old football player sustains a severe thigh contusion. Three weeks later, he presents with worsening pain and decreased knee flexion. Radiographs show calcification in the anterior thigh. What is the most appropriate initial management?

Explanation

Myositis ossificans traumatica is best managed non-operatively initially with NSAIDs (such as indomethacin) and gentle active range of motion. Early surgical excision is contraindicated as it exacerbates the inflammatory process and leads to high rates of recurrence.

Question 78

A 35-year-old water skier falls and sustains a forced hyperflexion injury of the hip with the knee extended. MRI demonstrates a complete 3-tendon proximal hamstring avulsion retracted 3.5 cm. What is the most appropriate management?

Explanation

Complete 3-tendon proximal hamstring avulsions retracted greater than 2 cm in active individuals are a strong indication for acute surgical repair. Non-operative management in this setting results in significant residual weakness, pain, and cramping.

Question 79

A 19-year-old female dancer complains of a painful clunking sensation deep in her anterior groin when extending her hip from a flexed, abducted, and externally rotated position. Ultrasound shows sudden tendon displacement. Which anatomic structure is most likely involved?

Explanation

Internal snapping hip (coxa saltans) is caused by the iliopsoas tendon snapping over the iliopectineal eminence or femoral head. It is characteristically reproduced by moving the hip from a flexed, abducted, and externally rotated position into extension.

Question 80

A 28-year-old marathon runner presents with lateral hip pain and a palpable snap when walking. The Ober test is strongly positive. If extensive non-operative management fails, what surgical intervention is most appropriate?

Explanation

External snapping hip is caused by a tight iliotibial band (ITB) slipping over the greater trochanter. Refractory cases that fail physical therapy and injections are treated with ITB lengthening, Z-plasty, or crucial release.

Question 81

A 24-year-old hockey player presents with chronic groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate an alpha angle of 65 degrees on the lateral view. What is the primary pathophysiologic mechanism of his joint damage?

Explanation

Cam impingement (alpha angle >55 degrees) features an aspherical femoral head that enters the joint in flexion, creating massive shear forces. This directly leads to anterosuperior acetabular cartilage delamination and labral tears.

Question 82

A 20-year-old rugby player sustains a direct blow to the anterior thigh. He is diagnosed with a quadriceps contusion. Which of the following is the most widely accepted clinical criterion for safe return to play to minimize the risk of re-injury?

Explanation

Return to play after a quadriceps contusion requires at least 120 degrees of pain-free active knee flexion and functional sport-specific agility. This milestone ensures adequate muscle flexibility to minimize the risk of re-injury and progression to myositis ossificans.

Question 83

A 30-year-old cyclist falls off his bike, sliding on his lateral hip. Examination reveals a large, fluctuant, soft tissue swelling over the greater trochanter with intact overlying skin. MRI confirms a fluid collection between the subcutaneous fat and the fascia lata. What is the most likely diagnosis?

Explanation

A Morel-Lavallée lesion is a closed degloving injury resulting from shearing forces that separate the subcutaneous tissue from the underlying fascia. This creates a potential space that fills with hemolymphatic fluid.

Question 84

In a patient diagnosed with athletic pubalgia (core muscle injury), MRI often shows edema and tearing at the pubic symphysis. This pathology most commonly involves the confluent aponeurosis of which two structures?

Explanation

Athletic pubalgia commonly involves an injury to the anterior pubic aponeurosis. This structure represents the confluent, intertwined insertion of the rectus abdominis and the adductor longus on the pubis.

Question 85

A 16-year-old soccer player experiences a sudden pop and sharp pain in his anterior pelvis while kicking a ball. Radiographs reveal a bony avulsion fragment displaced 1 cm inferiorly from the anterior inferior iliac spine (AIIS). Which muscle is responsible for this avulsion?

Explanation

The direct head of the rectus femoris originates from the anterior inferior iliac spine (AIIS), while the reflected head originates from the superior acetabular rim. Vigorous kicking mechanisms commonly cause avulsion fractures of the AIIS in adolescents.

Question 86

A 40-year-old female presents with chronic deep posterior hip pain that radiates to the posterior thigh. MRI shows narrowing of the space between the lesser trochanter and ischial tuberosity with prominent edema in the quadratus femoris muscle. What is the most likely diagnosis?

Explanation

Ischiofemoral impingement occurs due to a pathologically narrowed space between the lesser trochanter and the ischial tuberosity. This mechanical impingement leads to compression and edema of the intervening quadratus femoris muscle.

Question 87

A 26-year-old professional soccer player presents with chronic, gradually worsening anterior pelvic pain. Examination shows point tenderness directly over the pubic symphysis. Radiographs reveal sclerosis and widening of the symphysis pubis. What is the most appropriate initial treatment?

Explanation

Osteitis pubis is a painful, non-infectious inflammatory condition characterized by sclerosis and widening of the pubic symphysis. The initial treatment is always non-operative, focusing on rest, NSAIDs, and progressive physical therapy.

Question 88

A 19-year-old American football player receives a direct helmet blow to the lateral iliac crest. He presents with severe pain, localized swelling, and difficulty walking. Radiographs are negative for fracture. What is the most appropriate initial management for this injury?

Explanation

A "hip pointer" is a severe contusion to the iliac crest and its muscular attachments. Management is conservative with rest, ice, compression, NSAIDs, and a gradual return to activity utilizing protective padding.

Question 89

A 55-year-old female presents with refractory lateral hip pain. She walks with a distinct Trendelenburg gait. An MRI reveals a full-thickness tear of the gluteus medius tendon at its insertion on the greater trochanter with fatty atrophy. What physical exam finding is most likely present?

Explanation

Gluteus medius tears present as recalcitrant greater trochanteric pain syndrome accompanied by a positive Trendelenburg sign. Patients exhibit profound weakness with resisted hip abduction in the lateral decubitus position.

Question 90

A hockey player sustains an acute grade II strain of the adductor longus muscle. He is prescribed a phased physical therapy program. During the remodeling phase, which type of exercise is most effective for promoting tissue healing and preventing recurrence?

Explanation

Eccentric strengthening exercises are critical in the rehabilitation of muscle strains, including the adductors and hamstrings. They promote proper collagen alignment, increase muscle fascicle length, and significantly reduce recurrence rates.

Question 91

A 45-year-old female presents with anterior hip pain. Radiographs demonstrate a crossover sign and a lateral center-edge angle of 45 degrees, consistent with global acetabular overcoverage. Which condition is most strongly associated with this morphology?

Explanation

A crossover sign and an increased lateral center-edge angle (>40 degrees) indicate acetabular retroversion or overcoverage. These are the classic radiographic hallmarks of Pincer-type femoroacetabular impingement.

Question 92

A 15-year-old track athlete hears a pop and experiences sudden pain in the anterior pelvis while sprinting. Radiographs show a small avulsion fracture of the anterior superior iliac spine (ASIS). Which two muscles attach at this anatomic site?

Explanation

The anterior superior iliac spine (ASIS) serves as the origin for the sartorius and the tensor fasciae latae (TFL) muscles. Avulsion fractures of the ASIS are common in sprinting adolescents and are typically treated non-operatively.

Question 93

A 32-year-old runner presents with deep gluteal pain radiating down the posterior thigh. Pain is reproduced with resisted external rotation of the hip. MRI of the lumbar spine is normal. The affected nerve passes through the greater sciatic foramen typically in what relation to the piriformis muscle?

Explanation

In classic piriformis syndrome, the sciatic nerve is compressed as it exits the pelvis through the greater sciatic foramen. In the majority of the population, the entire nerve passes immediately inferior to the piriformis muscle belly.

Question 94

A 40-year-old marathon runner complains of chronic, localized pain over the ischial tuberosity that worsens during prolonged sitting and uphill running. Which clinical test is most specific for diagnosing proximal hamstring tendinopathy?

Explanation

The modified bent-knee stretch test and the Puranen-Orava test place maximal tension on the proximal hamstring origins. They are highly sensitive and specific clinical maneuvers for diagnosing proximal hamstring tendinopathy.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 44

Orthopedic Prometric MCQs - Chapter 3 Part 44

Chapter Index